Massage Establishment Registration Application Instructions

THE STATE of ALASKA Department of Commerce, Community, and Economic Development Division of Corporations, Business and Professional Licensing Board of Massage Therapists PO Box 110806, Juneau, AK 99811-0806 (907) 465-2550 Email: BoardOfMassageTherapists@Alaska.Gov Website: pists Massage Establishment Registration Application Instructions Please read the application and instructions carefully. Failure to do so may cause additional correspondence and delay in the processing of your application. WHO MUST REGISTER THEIR MASSAGE ESTABLISHMENT? Any owner of a massage therapy establishment who is not exempted under 12 AAC79.930(b) must register their massage therapy establishment. The majority owner of a massage establishment is exempt from registering their massage therapy business if they hold an active, current professional license in Alaska for: (1) acupuncturist under AS 08.06; (2) chiropractor under AS 08.20; (3) naturopath under AS 08.45; (4) massage therapist under AS 08.61; (5) physician, osteopath, mobile intensive care paramedic, or physician assistant under AS 08.64; (6) direct-entry midwife under AS 08.65; (7) advanced practice registered nurse under AS 08.68; or (8) physical or occupational therapist under AS 08.84. WHAT IS A MASSAGE THERAPY ESTABLISHMENT? A “massage therapy establishment” means a fixed or mobile place of business that is: (1) owned by a natural person, partnership, limited partnership, corporation, company, limited liability company, or other entity; (2) engages in, conducts, or permits massage or massage therapy to be conducted for any form of compensation, or uses the word “massage” in any solicitation or advertisement. INITIAL APPLICATION An owner must register each massage therapy establishment separately. The following must be received by the division before the application will be reviewed: 1. 2. 3. APPLICATION A completed application, signed and notarized FEES Payment of the required Non-Refundable Establishment Registration Fee of 300.00. SELF-INSPECTION REPORT & CHECKLIST A completed Self Inspection Report & Checklist (form #08.4733a), signed and notarized. IT IS ILLEGAL TO OPERATE A MASSAGE ESTABLISHMENT IN ALASKA WITHOUT AN ACTIVE REGISTRATION. 08-4733 (Rev. 11/17/2020) Application Instructions Page 1 of 1

CHANGE OF OWNERSHIP An Establishment registration is not transferable to another person or entity. The new owner or entity must apply for a new Establishment Registration within 30 business days of acquiring the establishment and before conducting business. CHANGE OF PHYSICAL LOCATION If the physical location of an establishment changes, the owner or entity must apply for a new registration within 30 business days of the change and before conducting business. POINT OF CONTACT (POC) A Point of Contact (POC) should be well versed in the massage therapist’s statutes and regulations and be available as an educational resource for the owner. The POC will also be a point of contact for the Licensing Examiner and the Investigative Staff should any questions arise. UNREGISTERED ESTABLISHMENTS Any establishment that is unregistered will be subject to an Investigative fee in the amount of 2,000.00 per 12 AAC 02.396(6). BUSINESS LICENSE REQUIREMENTS A State Business License is required for a business operating in the state. Please contact the Business Licensing Section at commerce.alaska.gov/web/cbpl/BusinessLicensing for information on obtaining a business license at 907-465-2550 in Juneau or 907-269-8160 in Anchorage. 08-4733 (Rev. 11/17/2020) Application Information Page 2 of 2

MAS THE STATE of ALASKA FOR DIVISION USE ONLY Department of Commerce, Community, and Economic Development Division of Corporations, Business and Professional Licensing Board of Massage Therapists PO Box 110806, Juneau, AK 99811-0806 (907) 465-2550 Email: BoardOfMassageTherapists@Alaska.Gov Website: pists Massage Establishment Registration Application PART I Payment of Fees Required Fees: Non-Refundable Registration Fee Type of Application: Initial Type of Business: Sole Proprietor PART II 300.00 Change of Physical Location Partnership Change in Ownership Corporation Owner Information LLC/LLP Majority Partner/Owner information If you have had a legal name change since your last license was issued, you must complete a Change of Name form. Full Name: This is a name change: Mailing Address: Street/PO Box City State Contact Phone: Zip Birthdate: Send my Correspondence by Email Email Address: Send my Correspondence by US Mail SOCIAL SECURITY NUMBER: AS 08.01.060 requires you to provide your United States Social Security Number. It is considered confidential information and will not be publicly disclosed; it may be used to verify inter-state licensure. Partner Information - If Applicable If you have had a legal name change since your last license was issued, you must complete a Change of Name form. Full Name: This is a name change: Mailing Address: Street/PO Box City State Contact Phone: Zip Birthdate: Send my Correspondence by Email Email Address: Send my Correspondence by US Mail SOCIAL SECURITY NUMBER: AS 08.01.060 requires you to provide your United States Social Security Number. It is considered confidential information and will not be publicly disclosed; it may be used to verify inter-state licensure. Corporation, LLC or LLP Information - If Applicable Corporate, LLC/LLP Name Name and Address of Corporation, LLC or LLP: 08-4733 Street/PO Box (Rev. 11/17/2020) City Application Page 1 of 3 State Zip

PART III Identification Doing Business As (DBA): Mailing Address of Establishment: Physical Address of Establishment: Street/PO Box City State Zip Street City State Zip Phone Number of Establishment: EMAIL AGREEMENT: By choosing to receive correspondence on any matter affecting my license or other business with the Alaska Division of Corporations, Business and Professional Licensing, I agree to maintain an accurate email address through the MY LICENSE web page. I understand that failure to check my email account or to keep the email address in good standing may result in an inability to receive crucial information, potentially resulting in my inability to obtain or maintain licensure. Send my Correspondence by Email Send my Correspondence by US Mail Email Address: PART IV Establishment Information Do you own other establishments? Each establishment must be registered separately. NO, I do not own any other establishments. YES, I own other establishments. 08-4733 (Rev. 11/17/2020) Registration Number(s): Application Page 2 of 3

MAS THE STATE of ALASKA FOR DIVISION USE ONLY Department of Commerce, Community, and Economic Development Division of Corporations, Business and Professional Licensing Board of Massage Therapists PO Box 110806, Juneau, AK 99811-0806 (907) 465-2550 Email: BoardOfMassageTherapists@Alaska.Gov Website: pists Notary Signature Page Applicant Name: PART V Agreement I hereby certify that I am the person herein named and subscribing to this application and that I have read the complete application, and I know the full content thereof. I declare that all of the information contained herein, and evidence or other documents submitted herewith are true and correct. I understand that any falsification or misrepresentation of any item or response in this application, or any attachment hereto, or falsification or misrepresentation of documents to support this application, is sufficient grounds for denying, revoking, or otherwise disciplining a license or permit to practice in the state of Alaska. I further understand that it is a Class A misdemeanor under Alaska Statute 11.56.210 to falsify an application and commit the crime of unsworn falsification. A person who makes a false statement on this application may be subject to civil and criminal penalties, including prosecution for perjury (AS 11.56.200 & AS 11.56.230). Notary Stamp Applicant’s Printed Name: Applicant’s Signature: 08-4733 Notary Public for State of: Subscribed and Sworn to Before me on this Day: Notary’s Signature: My Commission Expires: (Rev. 11/17/2020) Application Page 3 of 3

THE STATE of ALASKA Department of Commerce, Community, and Economic Development Division of Corporations, Business and Professional Licensing Board of Massage Therapists PO Box 110806, Juneau, AK 99811-0806 (907) 465-2550 Email: BoardOfMassageTherapists@Alaska.Gov Website: pists Massage Establishment Self-Inspection Report & Checklist To be completed by owner Establishment Name: Owner Name: Street Physical Location: Phone Number: City State Zip Fax Number: mm/dd/yyyy Date of Self-Inspection: Please Identify the Point of Contact as well as other massage therapists working in the establishment. Massage Point of Contact: License Number: List all additional employed massage therapists below: Name of Massage Therapist 08-4733a (Rev. 11/17/2020) License Number Massage Establishment Self-Inspection Report Page 1 of 2

Massage Establishment Self-Inspection Report Checklist Item 1. The owner has designated a licensed therapist who practices in this location as the Point of Contact. 2. A current copy of the Code of Ethics, Standards of Practice, and Establishment Standards of Operation must be on the premises and made available to the public on request. 3. In full public view, current massage licenses of all employed massage therapists. 4. The owner has a written and or digital system of maintaining client records for at least five (5) years. This includes safeguarding verbal and written confidential information of the client, unless disclosure is required by law, court order or authorized by the client. 5. The owner maintains all equipment used to perform massage therapy services on the premises in a safe and sanitary condition. 6. The owner will maintain compliance with all applicable state and local building and fire codes. 7. The owner will provide for removal of garbage and refuse in a sanitary manner. 8. The owner will provide for safe storage cleaning, and/or removal of soiled linens. 9. Rooms or any cubicle for massage or massage therapy practices may not be equipped with an externally locking door. YES NO Comments 10. Establishment shall not operate or be open for business between the hours of 12:00 a.m. and 5:00 a.m. 11. No owner, operator, or employee shall allow television, video, or recording equipment in any room where massage services are being provided. A security surveillance monitor that can only receive images of the inside of the common areas of the establishment is allowed. With written client consent, a massage therapist may use video and photography equipment for therapeutic purposes. 12. Will comply with the Standards of Operation at all times. I certify that the above information is true and correct. A person who makes a false statement on this application may be subject to civil and criminal penalties, including prosecution for perjury (AS 11.56.200 & AS 11.56.230). NOTARY STAMP Owner’s Signature: Owner’s Name: 08-4733a Notary Public for State of: Subscribed and Sworn to Before me on this Day: Notary’s Signature: My Commission Expires: (Rev. 11/17/2020) Massage Establishment Self-Inspection Report Page 2 of 2